My friend and colleague from the New America Foundation, Michael Lind, has a provocative article in Salon on health reform -- well, the headline is provocative ("More Raw Deal than New Deal"), but the substance is actually a thoughtful and somewhat complicated journey through his own evolving thinking about health reform since he and Ted Halstead pushed an individual mandate to buy insurance in their 2001 book, The Radical Center.
The core of Lind's argument is that from the point of view of his preference for a "citizen-based social contract" (meaning only that benefits belong to the individual, rather than being contingent on employment or complicated eligibility), he now prefers a mandate on employers to provide insurance to the mandate on individuals to obtain it. The Obama plan, he says, is evolving toward "pay or play ... the status quo, modified slightly by a baffling Rube Goldberg scheme for covering the uninsured," not the kind of uniform benefit characteristic of New Deal programs.
Lind puts particular weight on the goal of "eliminating a multi-tier labor force that allows businesses to game the system -- for example, by outsourcing some tasks to private contractors, in order to avoid paying health benefits to full-time workers." A uniform employer mandate would prevent this, he argues.
Lind introduces a critically important idea to the health-care debate: Social solidarity. We already have a two-tier labor force, often within a single company, in which some people have health care and job security and others are vulnerable in every way, even while working. Pulling us apart in that way has social and political consequences that are deeper than the economic consequences. And a good question to ask about any policy is whether it would make that problem better or worse.
Just coupling a poorly designed public option to the existing health-care system might indeed worsen that sense of stratification by creating a third undesirable layer between private insurance and Medicaid, even if fewer people were technically "uninsured." But I'm not sure that an employer mandate is the solution. For one thing, it's almost impossible in Congress to avoid exempting small businesses, usually those with under 50 employers. That brings all the outsourcing and independent contracting games right back in, and leaves millions out of the mandate. Second, it still falls short of a seamless system where insurance doesn't change if you leave your job. And you would still want to create the insurance systems and even a public plan that smaller employers could buy into.
So I don't follow Lind all the way. I think a robust public option coupled with insurance exchanges all tied to a roughly comparable basic package of benefits, paid for by employers or individuals, with a subsidy, can create a system that feels uniform and fair, and doesn't further pull us apart. But he's put an important idea on the table, and I'll certainly watch the legislative dance with an eye to whether it would pull the tiers of the economy further apart, or bring them together.
-- Mark Schmitt